‘No good evidence’ for gender care for youth over long-term, review finds

Study commissioned by England’s health service says hormones should only be prescribed to teens with ‘extreme caution’.

The evidence behind medical intervention for youth questioning their gender is “remarkably weak”, with some doctors abandoning “normal clinical approaches” to prescribe hormones to teens, a landmark review in the United Kingdom has found.

The long-term health effects of masculinising and feminising hormones on teens are “limited and need to be better understood” and such interventions should only be taken with “extreme caution”, the long-awaited review commissioned by England’s National Health Service (NHS) said on Wednesday.

Puberty blockers, which are given to pre-teens to delay puberty, were not found to relieve gender dysphoria or improve “body satisfaction” and evidence about their effects on psychological wellbeing, cognitive development and fertility was insufficient or inconsistent, the review said.

There was also no evidence that puberty blockers “buy time to think”, since the vast majority of young people on them proceed to hormone treatment, according to the review.

Hilary Cass, a paediatrician at St Thomas Hospital in London, led the four-year review into services provided by the NHS for young people questioning their gender identity.

The review relied on analyses of evidence conducted by the University of York, which examined current guidelines for managing gender dysphoria and the results of dozens of studies on hormones and puberty blockers.

Cass said that while doctors were usually cautious about implementing new research findings in fledgling areas of medicine, “quite the reverse happened in the field of gender care for children”.

“Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries,” Cass said in a foreword to the report.

“This was closely followed by a greater readiness to start masculinising/feminising hormones in midteens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch Study.”

“Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations,” Cass added.

“They deserve very much better.”

Cass also expressed concern about the “exceptional” toxicity of the public discussion about transgender and gender-questioning youth.

“I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution. The knowledge and expertise of experienced clinicians who have reached different conclusions about the best approach to care are sometimes dismissed and invalidated,” Cass said.

“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

Cass said that studies were “exaggerated or misrepresented” on all sides of the debate despite this being an area with “remarkably weak evidence”.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” she said.

The review was not intended to undermine the validity of transgender identities or roll back people’s right to healthcare, Cass said, but about how to “best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity.”

The NHS commissioned the review in 2020, amid a sharp rise in the number of young people questioning their gender identity and concerns that some minors were being inappropriately identified as transgender.

The NHS last month announced it would no longer prescribe puberty blockers for children and young people outside of clinical research trials.

The UK’s first gender identity clinic for children, operated by the Tavistock and Portman NHS Trust, closed last month after years of criticism that it rushed minors into changing their gender.